Alaska Regional Hospital

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 42377 . Based on record review and interview, the facility failed to implement an effective discharge process by ensuring the patient received the prescribed discharge medication necessary to continue treatment after hospitalization for 1 patient (#14) out of 19 sampled patients as required by the Code of Federal Regulations (CFR) §482.43. Specifically, the facility did not ensure that a prescription for penicillin (an antibiotic) was provided to the patient or successfully transmitted to Patient #14’s pharmacy of choice at the time of discharge. This failure placed the patient at risk for not receiving the prescribed antibiotic therapy after discharge, disrupted the continuity of care, and increased the potential for clinical deterioration and hospital readmission. Findings: Record review on 6/30/26 -7/1/26, revealed Patient #14 was admitted to the facility with diagnoses that included chronic osteomyelitis (persistent bone infection), wound dehiscence (wound or incision reopened) and anemia (low red blood cells). Review of the “Adult Infectious Disease Progress Note,” dated 5/14/26, revealed: “ ...Our only options for antibiotics that likely match C [Corynebacterium] striatum [an opportunistic pathogen capable of causing infection], C [Cutibacterium] acnes [a bacteria that is a normal component of human skin flora] and group a strep [Group A beta-hemolytic streptococcus- a bacteria that can cause wide range of infection] is penicillin ...ASSESSMENT AND PLAN: 1. Will hope penicillin will work for the multitude of small volume gram positive organisms we’ve found in the shoulder. If she rashes out again or continues to have signs/symptoms of infection I would recommend stopping all antibiotics x 1 week and repeating washout ...Plan discussed with patient/family ...” Review of the “Discharge Summary,” dated 5/14/26, revealed “ ...ID [Infectious Disease physician] was consulted for management of antibiotics, [Patient#14] was on IV [intravenous] antibiotics in-house and was switched to oral penicillin prior to discharge ...Plan Continue oral antibiotics ...” Further review of the discharge summary, revealed “Discharge Medications ...START taking ...penicillin v [Vertraulich] potassium 500 MG [milligrams] tablet Take 1 tablet (500 mg total) by mouth every 6 (six) hours For: Skin and Soft Tissue Infection Quantity:120 tablet Refills:1 ...” Review of the “Outpatient Medication Detail” of the penicillin v potassium 500 mg tablet, signed on 5/14/26 at 2:08 PM, revealed: “E [electronic]-Prescribing Status: Transmission to pharmacy failed ... acknowledged by Licensed Nurse (LN) #1 on 5/14/26 at 2:11 PM. During a joint interview on 6/30/26 at 2:49 PM with the Pharmacist #1 and the Pharmacy Director (PD), Pharmacist #1 stated when the patient would be discharged, the physician would send the order to the patient’s pharmacy of choice or receive printed prescriptions. Pharmacist #1 further stated the “in-patient” pharmacy was not involved in the transmission of the prescription to the outside pharmacy. During a joint interview on 7/1/26 at 10:22 AM with LN #1 and the Director of Medical Surgical (DMS), LN #1 and the DMS were not aware of the prescription transmission failure. The DMS stated the hospital process was that the pharmacy would call the hospital, then the charge nurse would talk to the physician to resend the prescription. During an interview on 7/1/26 at 1:00 PM with the Director Clinical Informatics (DCI), he confirmed the penicillin prescription transmission failed. He stated normally, the prescription would be sent electronically to the pharmacy. If there was no connection with the receiving pharmacy, the message would be sent back to work queue (an automated system process to detect errors) and that message would go back to the prescribing physician in EPIC (facility’s electronic health record system). He further stated, the hospital third party analyst could not verify that this had happened. When asked about the LN #1’s acknowledgement of the medication order, he stated the nurse acknowledged that the order was placed but the nurse would not know if the transmission had failed. During an interview on 7/1/26 at 2:35 PM with the DCI, he stated that in EPIC system had an “in basket (an internal mailbox).” He confirmed that upon review with the hospital’s third-party analyst, there was no evidence that the prescribing physician checked the “in basket” on 5/14/26. He stated all other prescriptions of Patient #14 were printed except for the penicillin. During an interview on 7/1/26 at 3:36 PM with the Quality Director (QD) stated when the prescription transmission failed, it could have been reordered with a printed prescription, or another attempt to send electronically to the pharmacy. The QD confirmed according to the hospital’s EPIC informatics team, there was no evidence that the prescription was resent electronically nor printed. During an interview on 7/1/26 at 3:58 PM, the Medical Director (MD) confirmed that prescribing physicians were not notified when an electronically prescribed discharge medication failed to transmit to the patient’s pharmacy. The MD stated physicians would not be aware the prescription had failed unless contacted by the patient or the pharmacy. Review of Patient #14’s electronic health record on 6/30/26 and 7/1/26 revealed the hospital did not have a process to ensure failed electronic discharge prescriptions were identified and corrected before the patient had left the hospital. Review of the facility’s “Discharge Planning” policy, dated 2/2022, revealed: “The discharge planning will begin on admission and continue throughout hospitalization ... PROCEDURE: RN [Registered Nurse] or designee will ...7. Complete ‘discharge instructions’ b ...Ensure patient ...has received prescriptions ...” .”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 40259 . Based on interview and record review, the facility failed to provide a Medical Screening Examination (MSE) for one individual (Patient #5) who presented to the Emergency Department (ED), with a police escort and under a Notice of Emergency Detention and Application for Examination, called a Title 47 (An Alaska Statue [AS], 47.30.705, which authorize the detention for emergency evaluation when considerations of safety do not allow initiation of involuntary commitment procedures), for assessment. This failed practice denied the individual an MSE, which violated the Emergency Medical Treatment and Labor Act (EMTALA), after it was requested on his/her behalf, in order to determine if stabilizing treatment was needed, or an appropriate transfer was required. Findings: Patient #5 During an interview on 4/17/24 at 8:20 AM, Police Officer #1 stated in the early morning of 2/8/24, Patient #5 was arrested after trespassing at a homeowner’s residence and was subsequently pepper sprayed by the homeowner. At the time of arrest, it was thought that Patient #5 had a warrant. Because Patient #5 was pepper sprayed and because of obvious untreated frostbite sores/wounds to both hands, Police Officer #1 took Patient #5 to the facility around 3:00 AM on 2/8/24 for a medical clearance prior to taking him/her to jail. Police Officer #1 drove his police vehicle into the facility’s ambulance bay, which was a garage-like enclosure with garage-type roller doors, that was situated just off the ED. Police Officer #1 further stated that while he/she was at the facility seeking treatment for Patient #5, it was determined that Patient #5 did not have a warrant. At that time, Police Officer #1 placed Patient #5 under a Title 47 for being gravely disabled. Police Officer #1 stated Nurse #8 came into the ambulance bay and cleaned Patient #5’s face of the pepper spray chemicals while Patient #5 sat in the back seat of the police vehicle. Police Officer #1 stated the nurse advised him/her that the facility was possibly on divert and their beds were full. After consulting with Anchorage Police Department (APD) dispatch, Police Officer #1 took Patient #5 to another hospital for treatment prior to an MSE being performed. Review of Patient #5’s “Notice of Emergency Detention and Application for Examination” (Title 47) form revealed: “Probable Cause: I certify that probable cause exists under AS 47.30.705 to believe that the above-named person is mentally ill and as a result of that condition is likely to cause serious harm to others of such an immediate nature that considerations of safety do not allow initiation of involuntary commitment procedures under AS 47.30.700. . . Information supporting probable cause. . . [he/she] was acting extremely erratic and uncontrollable. [Patient #5] appeared to have frostbite to both of [his/her] hands that were poorly care for. Given [Patient #5’s] mental state [he/she] did not appear to have the ability to care for [his/her] injuries in addition to being not properly dressed for the weather. . .” Facility Encounter on 2/8/24 at 3:00 AM Record review on 4/15-16/24 revealed Patient #5 was not listed in the ED log of encounters, nor did he/she have an active medical record with his/her name or date of birth for 2/8/24. Review of the facility’s ED log, dated February 2024, revealed an encounter, dated 2/8/24 at 3:00 AM, however the name was a location, “Albertville, Uganda.” Further review revealed the arrival method was “police” and the discharge disposition was documented as “left prior to med screening exam.” Further review revealed no documentation for chief complaint, ED disposition, or ED discharge disposition. Review of this “Albertville, Uganda” medical record, dated 2/8/24, revealed three nurse’s notes: - 2/8/24 at 3:02 AM: “Went to ambulance bay to look at patient and to speak with officer. Patient sitting in the back of vehicle. Officer asked if the ED was busy. I stated that “we are busy but then everyone was.” Officer then stated he would find out who was next in rotation for the next title 47 patient. He then asked if I could clean patient’s face. When I returned with supplies the officer stated that [a secondary hospital] was the next in line to receive the next title 47 patient. I asked if he was sure and he said “yes.” - 2/8/24 at 3:07 AM: “Patient had been pepper sprayed and police requested that [his/her] face be washed. Face cleaned with milk and rinsed with saline. Patient appeared more comfortable after cleaning.” - 2/8/24 at 3:08 AM: “Officer did not provide full name or date of birth as he intended to leave with patient to Providence [hospital] based on own preference.” Further review of this medical record revealed a birthdate of 2/8/99 (which would have indicated the patient was 25 years old). No other documentation was included in this medical record, no MSE was documented as being performed by a physician on 2/8/24. During an interview on 4/16/24 at 12:46 PM, the Quality Director stated the facility completed an investigation after leadership was alerted to a potential EMTALA violation on 2/8/24. Through video camera recording review and interview it was determined an EMTALA violation had occurred, as care was rendered to a patient in the ambulance bay by a nurse, however no MSE was completed. An observation on 4/16/24 at 1:15 PM, of the video camera recording of the ED ambulance bay, from 2/8/24 at 3:00 AM, revealed the following: - 3:00 AM: Nurse #13 entered the ambulance bay and opened the roller door of the bay. Police Officer #1 drove his police vehicle into the ambulance bay. A second Police Officer was observed to walk into the ambulance bay. Nurse #13 closed the ambulance bay door. Nurse #13 was observed to talk to the Officers in the ambulance bay. - 3:02:25 (hour, minute, second) AM: Nurse #13 was observed to leave the ambulance bay. The two Police Officers stood in the ambulance bay, outside of the police vehicle. - 3:07:25 AM: Nurse #8 observed to enter the ambulance bay and talk with the Police Officers. - 3:09:56 AM: Nurse #8 left the ambulance bay. - 3:11:57 AM: Nurse #8 returned to the ambulance bay with supplies. Nurse #8 placed medical supplies on the hood of the police vehicle and donned gloves. Nurse #8 poured liquid onto a cloth. - 3:13:50 AM: Nurse #8 approached the backseat of the police vehicle and was observed to reach into the vehicle with the cloth. - 3:14:16 AM: Nurse #8 prepared a second cloth by pouring liquid onto it and then returned to the backseat of the police vehicle. - 3:16:00 AM: Nurse #8 gathered supplies off the police vehicle. - 3:16:26 AM: Nurse #8 left the ambulance bay. The second Police Officer left the ambulance bay. - 3:16:40 AM: Police Officer #1 opened the ambulance bay. - 3:17:21 AM: Police Officer #1 backed out of the ambulance bay and left the facility premises. During an interview on 4/16/24 at 1:32 PM, Nurse #8 stated during his/her shift on 2/8/24 at around 3:00 AM the facility received a request from a Police Officer to open the ambulance bay door. Nurse #13 went into the ambulance bay and opened the doors. Nurse #8 stated he/she could hear screaming and yelling coming from the ambulance bay, so he/she went out there to investigate. Nurse #8 stated the Police Officer mentioned, “it looks like you are busy.” Nurse #8 stated he/she responded that they were, but that everyone was busy everywhere. Nurse #8 stated the Police Officer stated he/she was going to call to see which hospital got the next “title” and asked if Nurse #8 would get something to clean off Patient #5’s face. Nurse #8 stated when he/she returned to the ambulance bay the Police Officer stated that a secondary hospital was the next hospital to receive a “title” and he would be taking the patient there. Nurse #8 further stated that he/she rendered care to the patient by washing Patient #5’s face with milk and rinsed with saline. When asked if Nurse #8 informed the ED physician that there was a patient in the ambulance bay, Nurse #8 stated no he/she had not. When asked if Nurse #8 was aware of the EMTALA obligation to provide individuals with an MSE when they come to the ED for care, Nurse #8 stated he/she was aware however, because the patient was in police custody, he/she thought the Police Officer had the autonomy to do whatever he/she wanted with the Patient. When asked if Nurse #8 observed any wounds on the patient, Nurse #8 stated he/she did observe that Patient #5’s had “old frostbite” skin peeling on fingers, however Patient #5’s hands were cuffed behind him/her and did not get a clear view of the wounds. When asked if the ED was open to receiving patients on 2/8/24 at 3:00 AM, Nurse #8 stated the ED was not closed to patients and was not on divert. When asked if the ED physician was available to see patients on 2/8/24 at 3:00 AM, Nurse #8 stated Physician #33 was available. Nurse #8 further stated after the Police Officer left with Patient #5, he/she alerted his/her Charge Nurse of the encounter and it was at this time that Patient #5’s information was logged into the ED log and the medical record documentation was made. Nurse #8 stated he/she never obtained Patient #5’s name or date of birth, so they made up a location as a name and created a date of birth for the medical record documentation. When asked how this was determined, Nurse #8 stated they just chose a place and guessed at a birthdate for an approximate year of age. During an interview on 4/6/24 at 2:02 PM, Nurse #13 stated that he/she was at lunch when he/she was asked to go into the ambulance bay to open the roller door for a Police Officer. Nurse #13 stated that once the officer was inside the ambulance bay, he/she conversed with the Police Officers and it was conveyed that Patient #5 had been pepper sprayed and they had brought Patient #5 to the ED to have his/her erratic behavior assessed, prior to and after being pepper sprayed. Nurse #13 stated he/she did not relay this information to nurses in the ED, and when he/she left the ambulance bay, he/she returned to his/her lunch break. When asked if cleaning a patient’s face of pepper spray was rendering care, Nurse #13 agreed this was rendering care. Nurse #13 stated it was a nursing role to prepare a patient for a physician’s assessment and this would include removing pepper spray chemicals so a thorough assessment could be performed. Nurse #13 stated a patient should have been assessed by a physician after being pepper sprayed to rule out any eye, nose, or respiratory trauma associated with the chemical. Review of the facility’s “Reason for Diversion” log, dated 2/6/24 through 2/8/24, revealed the ED was not on diversion on 2/8/24 at 3:00 AM. Secondary Facility Medical Record Review Review of Patient #5’s medical record at the secondary hospital, dated 2/8/24 at 3:42 AM, revealed Patient #5, who was 28 years old, received an MSE which revealed the need to admit the patient due to the following concerns: - Frostbite injuries, bilateral hands - History of polysubstance abuse, with acute intoxication, and agitation - Acute kidney injury, rhabdomyolysis - Hypertension - Possible sepsis - Positive antibody for hepatitis C - Prophylaxis for DVT (deep vein thrombosis) Patient #5 was admitted to the hospital on 2/8/24 and discharged on 3/2/24. Policy Review Review of the facility’s policy “Hospital EMTALA Central Log,” dated 9/2023, revealed: “. . . The hospital will maintain a Central Log containing information on each individual who comes on the hospital campus requesting assistance or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment, whether he or she left before a medical screening examination (“MSE”) could be performed, whether he or she refused treatment, whether he or she was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged. . .The logs must contain at a minimum: the name of the individual, or adequate identification; the date and time of the individual’s arrival; an emergency record number for the individual; the nature of the individual’s complaint; the individual’s disposition; whether the individual: refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was discharged, or expired; the time of the individual’s departure; and the individual’s condition on departure. . .” Review of the facility’s policy “Hospital EMTALA Medical Screening Examination and Stabilization,” dated 9/2023, revealed: “ ... An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (“DED”) and: 1. The individual or a representative acting on the individual’s behalf requests an examination or treatment for a medical condition ... A hospital must provide an appropriate MSE within the capability of the hospital’s emergency department, including ancillary services routinely available to the DED, to determine whether or not an EMC [emergency medical condition] exists ... [to] an individual who has such a request made on his or her behalf ...” Further review revealed: “ ...Note: A hospital my deny access to individuals when it is in “official diversionary” status because it does not have the capability or capacity to accept any additional emergency individuals at the time. The hospital shall develop and adopt written criteria that describe the conditions under which any or all of the hospital’s emergency services are deemed to be at maximum capacity. Caution: If the ambulance staff disregards the hospital’s instructions and brings the individual on to hospital property, the individual has come to the emergency department and the hospital must perform an appropriate MSE ...” Review of Alaska Statute (AS) 47.30.705(a) revealed: “A peace officer ... who has probable cause to believe that a person is gravely disabled or is suffering from mental illness and is likely to cause serious harm to self or others of such immediate nature that considerations of safety do not allow initiation of involuntary commitment procedures set out in AS 47.30.700, may cause the person to be taken into custody by a peace officer ... and delivered to the nearest ... evaluation facility or treatment facility ...” .”